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Running PDSA cycles

D1X XPatricia ChristoffD2X X

The need to change the delivery of healthcare in the United the “study” phase. Last, the plan is either adopted, adapted, or
States has been the focus of several recent publications. Quality abandoned in the “act” phase based on the evaluation of the
improvement concepts initially utilized in industry have been data in the prior step. The learning from one cycle should guide
applied to healthcare to reduce error and variation in out- the cycles that follow.
comes. The Plan-Do-Study-Act (PDSA) Methodology is one of A hypothetical example from an actual Quality Improvement
the most commonly used tools in quality improvement. Initiative sponsored by the American Academy of Pediatrics
The PDSA cycle is an iterative, four step model for improving Chapter Quality Networks provides a step by step approach to
a process. The first step is the development of a plan in which application of the PDSA model. Changes noted following multi-
predictions of outcomes are clearly stated and tasks are ple iterative PDSA cycles resulted in significant improvement in
assigned. It is in this phase that the who, what, when, and healthcare outcomes.
where of the plan is decided. In the “do” phase, the plan is
implemented. Data and results obtained are then analyzed in Curr Probl Pediatr Adolesc Health Care 2018; 000:1 4

Overview Improvement5 (Fig. 1). Change must occur for any

improvement effort to be successful. First, clearly
espite numerous advances in medicine, the deliv- define the purpose or aim of the improvement effort.
D ery of healthcare in the United States invites
change. The publications To Err is Human1 and
Second, determine specifically what and how data will
be collected in order to assess if a change has occurred;
Crossing the Quality Chasm2 highlight the challenges and this must be decided prior to undertaking the change.
call for renewed efforts to create a system that provides Third, develop a change that is predicted to result in
effective, efficient, and affordable patient care. A pioneer improvement; this leads into the PDSA cycle.
in this initiative, a PDSA cycles Interventions are chosen and
are among the most frequently
used tools in healthcare quality PDSA cycles are among the most tested through the Plan-Do-
Study-Act cycles to determine if
improvement. pediatrician named frequently used tools in healthcare the selected interventions help the
Donald Berwick borrowed quality quality improvement. team accomplish their aim.
improvement concepts utilized in PDSA cycles are an iterative, four
industry in an attempt to provide step model for improving a pro-
Each test of change should be
tested individually and on a small Each test of change should be cess.
Plan means developing a plan
scale. strategies that reduce error tested individually and on a small with identified tasks and task
and variation in healthcare out- scale. owners as well as identifying
comes.3 Of several methodologies when, how, and where the plan
studied, such as six-sigma, lean, will be implemented. Specific
and the PDSA cycle (Plan-Do Study-Act), the PDSA objectives as well as predictions of outcome should be
cycle is the most commonly used tool in healthcare qual- stated in this phase.
ity improvement.4 Do means carrying out the plan and documenting
PDSA methodology figures predominantly in the relevant data that identify successes, problems, or
Institute for Healthcare Improvement’s Model for unexpected outcomes. Although this step may seem to
be the most important, the “Study” phase is crucial to
From the Dayton Children’s Hospital, One Children’s Plaza, Dayton, OH
the overall process.
45404, USA. Study (evaluate) the documented data to determine if
Curr Probl Pediatr Adolesc Health Care 000;000:1 4 the plan is working. Results are compared to those
1538-5442/$ -see front matter predicted as well as those of previous performances
Ó 2018 Published by Elsevier Inc.
https://doi.org/10.1016/j.cppeds.2018.08.006 and learnings are discussed and documented.

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Act means the intervention being tested is adopted, of the key drivers, “partnering with parents for effec-
adapted, or abandoned based on the evaluation of the tive ADHD management” and identified the following
data in the prior phase. Here the next problem solving measure to improve: “the average time to obtain the
steps are described. A planning worksheet found in first set of parent follow-up scores since beginning
Fig. 2 may provide further guidance in the creation of ADHD treatment”. Some potential tests of change to
the PDSA cycle. improve parental completion of the scores included
creating an office process which could:
Healthcare example 1 prevent scheduling of ADHD follow-up visit or
One recent example of using PDSAs is a project from medication refills until parent rating scales are
the American Academy of Pediatrics Chapter Quality complete
Network (CQN) entitled the 2 contact parent if they have
“ADHD PDSAs help us to focus not filled out rating scale
on building fundamental knowl- PDSAs help us to focus on build- within 7 days
edge (i.e. learning) necessary to ing fundamental knowledge (i.e. 3 include a reminder to com-
enable improvement. Change learning) necessary to enable plete the rating scale in
Package”. As with all CQN proj- improvement. appointment reminder script
ects, it followed the Institute for 4 require having rating scales
Healthcare Improvement’s mod- filled out in the office on day
6
els . The purpose of the project was to help pediatric prac- of office follow-up appointment
tices create reliable processes and systems which enable
provision of a higher quality of care of patients with atten-
tion deficit and hyperactivity disorder (ADHD). Six evi- Because each test of change should be tested indi-
dence based key drivers were the foundation of the vidually and on a small scale, one team began their
change package.6 PDSA cycle with one patient, choosing to investigate
In this example, a pediatric practice focused on one process #1 and prevent scheduling of ADHD follow-up
visits or medication refills until the parent rating scales
were completed. They studied the results and docu-
mented success in that the parents of this first patient did
complete the rating scales. Adopting the measure, they
then ramped the second PDSA cycle up to testing three
patients and found similar results. Predicting they would
encounter the same success in five patients, the team
attempted the intervention in five patients, however
noted that two of the five did not receive their ADHD
medications for an entire month due to the lack of com-
pletion of the rating scales. This untoward effect caused
the team to abandon this process and attempt a new
PDSA cycle. (Fig. 3)
This pediatric team demonstrated appropriate use of
the five essential components of a PDSA cycle identi-
fied below by Taylor et al.7

1 Objectives of the test as well as a prediction of out-

come in the “Plan” phase should be analyzed and
compared to the actual outcome.
2 Small tests of change should be completed in the
FIG 1. The PDSA cycle is shorthand for testing a change by devel-
oping a plan to test the change (Plan), carrying out the test (Do), “Do” phase and adapted according to feedback
observing and learning from the consequences (Study), and where problems, successes, and unexpected obser-
determining what modifications should be made to the test (Act).5 vations are documented.

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FIG 2. The Plan-Do-Study-Act worksheet.

3 Data should be collected over time, which, when set of parent follow-up scores from the beginning of
plotted, will provide a visual image of how change the ADHD treatment increased from 58% at baseline
impacts the outcome. to 83% at the end of the project.
4 Multiple, repeated, and linked cycles should be
conducted with lessons learned reported to the
group from each prior cycle. Summary
5 Learnings from one cycle should guide the cycles
that follow in an iterative format where change is PDSA cycles are among the most frequently used
adopted, adapted, or abandoned. tools in healthcare quality improvement. When utili-
zation of all components of the PDSA methodology
are documented, significant improvements in care and
By conducting a variety of PDSA ramps over time, in patient outcomes have been reported.3-4,6-7 PDSAs
one CQN chapter was eventually able to develop a help us to focus on building fundamental knowledge
process whereby the average time to obtain the first (i.e. learning)8 necessary to enable improvement.

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TEST 1 TEST 2 TEST 3

PLAN : PLAN: PLAN:
What: Prevent ordering medicaon if What: Prevent ordering medicaon if What: Prevent ordering medicaon if
parent rang scale incomplete for one parent rang scale incomplete for parent rang scale incomplete for five
paent three paents paents
Who: Provider Who : Provider Who: Provider
Where: Office Where: Office Where: Office
Who executes: Provider Who executes: Provider Who executes: Provider
When: by July 1 When: by July 15 When: by July 30
DO: Meds not ordered for one paent DO: Meds not ordered for three DO: Meds not ordered for five paents
if form incomplete paents if forms incomplete if forms incomplete
STUDY: Parent completed form. STUDY: Parents completed from. STUDY: Two of five paent did not
Paent received medicaon Paents received medicaon receive medicaons for one month.
ACT: Adopt ACT: Adopt ACT: Abandon

FIG 3. PDSA ramp highlighting one test of change to improve the treatment of ADHD.

References 5. Langley G, Moen R, Nolan K, et al. The Improvement Guide.

1. Kohn LT, Corrigan J, Donaldson MS, Kohn L. To Err is Human: 2nd ed. Jossey-Bass San Francisco; 2009.
Building a Safe Health System. Washington, DC: National Acad- 6. Epstein J, Langberg JM, Lichtenstein PK, et al. The myADHD-
emy Press; 1999. portal.com Improvement Program: An innovative quality
2. Institute of Medicine (US). Committee on Quality of Health Care in improvement intervention for improving the quality of ADHD
America. Crossing the Quality Chasm: A New Health System for care among community-based pediatrician. Clin Pract Pediatr
the 21st Century. Washington, DC: National Academy Press; 2001. Psychol 2013;1(1):55–67.
3. Berwick D. Developing and testing changes in delivery of care. 7. Taylor M, McNicholas C, Nicolay C, et al. Systematic review
Ann Intern Med 1998;128(8):651–6. of the application of the plan-do-study-act method to improve
4. Varkey P, Reller, Resar RK, et al. Basics of quality improve- quality in healthcare. BMJ Qual Saf 2014;23:290–8.
ment in health care. Mayo Clin Proc 2007;82(6):735–9. 8. Roehrs S. Building profound knowledge. Curr Probl Pediatr
Adolesc Health Care 2018: In press.

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